Provider Demographics
NPI:1093044281
Name:NAVAL HEALTH CLINIC GREAT LAKES ILLINOIS
Entity Type:Organization
Organization Name:NAVAL HEALTH CLINIC GREAT LAKES ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT HOSPITAL CORPSMAN
Authorized Official - Prefix:MISS
Authorized Official - First Name:JOHNNA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-688-5568
Mailing Address - Street 1:3350 ILLINOIS STREET
Mailing Address - Street 2:BLDG 1523
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-5230
Mailing Address - Country:US
Mailing Address - Phone:847-688-5568
Mailing Address - Fax:847-688-4430
Practice Address - Street 1:3350 ILLINOIS ST
Practice Address - Street 2:BLDG 1523
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-5230
Practice Address - Country:US
Practice Address - Phone:847-688-5568
Practice Address - Fax:847-688-4430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1102XAmbulatory Health Care FacilitiesClinic/CenterMilitary Outpatient Operational (Transportable) Component